Ronburtontrainingvillage.org

RON BURTON TRAINING VILLAGEWARNING AND INFORMED CONSENT/RELEASE/WAIVER/CONVENANTCamper’s Name: _____________________________________ Date of Birth:Parent/Guardian Full Name:In consideration of ___________________________________________ (the “camper”) having been provided the opportunityFull Name of Camperto participate in the activities at and of the Ron Burton Training Village (RBTV), the camper and his parent or guardian hereby voluntarily agree as follows:RELEASE OF LIABILITY AND CONVENANT NOT TO SUE: Each camper and his parent or guardian agrees, for himself and his personal representatives, executors, administrators, heirs, next of kin, successors and assigns, to release, indemnify and forever discharge Ron Burton Training Village, Camelot Camp, Action Fitness or any of its subsidiaries, the Boston Red Sox, Major League Baseball, the American League of Professional Baseball Clubs (the “A.L.”), the New England Patriots, the National Football League, each person or owners (direct and indirect), sponsors, officers, directors, operators, boards, affiliates, instructors, employees, agents and servants of each of the foregoing (collectively, the “Releasees”), from, and waive in respect of each Releasee and covenant not to sue nay Releasee for, any and all losses, damages, demands, costs, expense, (including, but not limited to attorney’s fees and expenses), actions, causes of actions, suits, obligations, judgments, compensation and claims of any nature whatsoever (collectively, the “Liabilities”) arising from, in the course of, based upon or related to any personal injury or death to, or damage to or loss of property of, the camper or his parent or guardian sustained in connection with the camper’s participation in RBTV. Such release, discharge, waive and covenant not to sue shall include, but not be limited to, any and all such liabilities caused in whole or in part by the negligence of any Releasee in connection with such Releasee’s involvement with RBTV (for example, in connection with such Releasee’s training of personnel).ASSUMPTION OF RISK: Each camper and his parent/guardian is aware of and understands that there are inherent risks involved in the camper’s participation in RBTV related activities and agrees to assume all risk of and responsibility for personal injury or death to, or damage to or loss of property of, the camper arising from, based upon or relating to the camper’s participation in RBTV. Such assumption of risk includes, but is not limited to, a full range of injuries from minor to severe and that the results could be lesions, breaks, paralysis, death or any other serious permanent disability, or damage to or loss of property, arising from, based upon or relating to the lack of skill of any camper, the improper conduct of any camper and the action or omission of any referee, coach, counselor or supervisor and any personal injury or death or damage to or loss of property, caused in whole or in part by the negligence of any Releasee. Each camper and his parent or guardian understands and agrees that, in the event of any injury to camper, none of the Releasees will be responsible for any decisions relating to medical treatment for camper or for such treatment itself.RIGHT OF PUBLICITY: Participation in RBTV constitutes permission to use the name, likeness or nay other identification of the camper fir advertising, promotion, publicity, video/film production, instructional or any other purposes in connection with RBTV or the business of any of the Releasees, in any medium, at any time and from time to time without compensation to or right of prior review or approval by the camper or his parent/guardian. Each of the camper and his parent/guardian agrees, for himself and his personal representatives, executors, administrators, heirs, next of kin, successors and assigns, to release and discharge each Releasee from, to waive in respect of each Releasee, and not to sue any Releasee for, any and all Liabilities arising from, based upon or relating to any claim for invasion of privacy, violation of right of publicity, defamation or appropriation, or any similar claim, in connection with any such use.REPRESENTATIONS: Each camper and his parents/guardian states that he has had full opportunity to ask any questions regarding RBTV that he may have, that he has read and understands this release, discharge, waiver and covenant not to sue, and has explained it to the camper and the he has been given the opportunity to review this release, discharge, waiver and covenant not to sue with any person he chooses, including a lawyer, and has done so to the extent that he wishes to do so. Each camper and his parent/guardian further states that the camper has been examined by a doctor within the past six months and I s in good physical condition, is physically fit to participate in RBTV and is not subject to any medical condition that pose or may pose a risk of harm or disability to him or others. The camper and his parent/guardian also agree that each has taken into account, fully understand ad are completely aware of the risks associated with the activities of the Ron Burton Training Village and agree to accept these risks as a condition of the camper participation.RON BURTON TRAINING VILLAGEMEDICAL FORMPlease complete all sections.
Camper’s name: __________________________________________________________________________
Date of Birth: __________________________________________ Age: _____________
Mother’s Cell phone: Mother’s Work phone:
EMERGENCY NOTIFICATION
Insurance Carrier (name): ________________________________________________________________
Policy Number (please make sure you include all numbers): ____________________________________
Who carries the health insurance: _________________________________________________________
Please provide a contact phone number for the insurance company (usually found on the back of the card).RON BURTON TRAINING VILLAGEMEDICAL FORMPlease complete all sections.
HAS YOUR CHILD HAD ANY OF THE FOLLOWING (Please circle):
Ever required an Epi Pen injection for a severe allergic reaction
Has the camper had any surgery to remove an organ (gallbladder, appendix)
Any chronic or recurring illness: _____________________________________________________________________
Name of Physician: _______________________________________________ Phone Number: __________________
Pertinent Family Medical History: ___________________________________________________________________
Parent’s note to camp director: (any confidential pertinent information that would help us understand your child better.)
This health record for _________________________________ is correct to the best of my knowledge. The camper
described here has my permission to engage in ALL activities except those noted by my physician or me. I authorize any
treatment from a medical facility and/or physician, to treat, hospitalize, perform tests, x--‐rays, perform surgery,
including anesthesia or injection or any other procedure that is required. I indemnify and hold blameless RON BURTON
TRAINING VILLAGE INC and CAMELOT CAMP INC. and all of its agents and affiliates free from any liability or claims
resulting from such treatment forever.
Signature of Parent/guardian: ____________________________________________ Date:
RON BURTON TRAINING VILLAGEMEDICAL FORMPlease complete all sections.
DOB: ______________________________________________________ Age: ________________
Height __________ Weight _________________ HCT/HGB _______________ U/A __________
EYES ________________________ LUNGS __________________
GLASSES ______________________ ABDOMEN ________________
EARS ________________________ HERNIA ___________________
NOSE ________________________ EXTREMITIES ______________
THROAT ______________________ SPINE/POSTURE _____________
HEART _______________________ SKIN ______________________
I have examined the person herein described and have reviewed the health history. It is my opinion that this
person is physically able to engage in supervised extracurricular activities and those activities at the Ron Burton
Training Village except for those noted.
Signature of Examining Physician: ______________________________________ Date:
** MANDATORY MASSACHUSETTS STATE LAW REQUIRES THAT WE HAVE ON RECORD A COPY OF THIS CHILD’S IMMUNIZATION RECORD, PLEASE ATTACH RECORD TO THIS FORM.RON BURTON TRAINING VILLAGEParental Authorization for Over--‐the--‐ Counter Medications/Prescription Drugs
Name of Camper ____________________________________________________________ Date of Birth _________________
Drug/Food Allergies _______________________________________________________________________________________
I, the parent or legal guardian of the above named camper, give permission to have the camp nurse or designated personnel by the camp nurse or camp director, give the following medications, either over--‐the--‐counter or as prescribed by a medical physician.
Please check and circle the dosage of any over--‐the--‐counter medicines my child CAN be administered.
____________ Tylenol (Acetaminophen) every 4 hours as needed for headache, mild to moderate pain. [Possible side effects: well
tolerated, rare hypersensitivity reaction. Adverse reactions: loss of appetite, nausea, diaphoresis, generalized weakness within first
12--‐24 hours. Later signs of toxicity, vomiting, right upper quadrant pain, elevated liver functions tests. Contraindications:
____________ Ibuprofen (Motrin) every 6--‐8 hours as needed for headache, muscular discomfort, mild to moderate pain. [Possible
side effects: well tolerated except with children who have asthma. Children with asthma may experience bronchospasms while taking this drug. Adverse reactions: headache, dizziness, fluid retention, nausea, diarrhea, prolonged bleeding time. Contraindications: hypersensitivity to Ibuprofen.]
_____________ Antacid (Tums) every 4 hours as needed for upset stomach, heart burn. [Possible side effects: constipation, nausea,
GI upset, loss of appetite. Contraindication: allergy to calcium, renal calculi, hypercalcemia.]
_____________ Imodium AD 1--‐2 tablets every 6 hours as needed for diarrhea. [Possible side effects: constipation]
_____________ Dayquil or Nyquil as needed for cold symptoms (no longer than 2 days in a row).
____________ Cough Drops as needed for a cough.
All medications will be stored at room temperature in the original container in a locked room. All campers must have a signed parental authorization from on file at the camp before ANY medication will be administered.
Please list all medications brought to camp that will be administered during camp.
Please include time of day usually given.